Provider Demographics
NPI:1891110755
Name:MIRANDA, CONNIE
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 BRENTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-2627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 BRENTWOOD AVE
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-2627
Practice Address - Country:US
Practice Address - Phone:937-935-1399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 087254164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse